Why the study?
Pressure-volume loop changes by CMR in cardiac amyloidosis patients with preserved LVEF and their potential as subtype differential diagnostic markers required investigation.
Do pressure-volume loop parameters derived from cardiac magnetic resonance imaging differentiate between light-chain and transthyretin-related cardiac amyloidosis in patients with preserved left ventricular ejection fraction?
Observational (n=140)
Do pressure-volume loop parameters derived from cardiac magnetic resonance imaging differentiate between light-chain and transthyretin-related cardiac amyloidosis in patients with preserved left ventricular ejection fraction?
CMR-derived pressure-volume loop parameters, particularly potential energy index combined with NT-proBNP, provide a non-invasive, contrast-free method to help differentiate between light-chain and transthyretin cardiac amyloidosis in patients with preserved LVEF.
PEI from CMR may aid noninvasive AL-CA vs ATTR-CA differentiation in preserved LVEF; leaves open prospective validation before changing practice.
Objectives To investigate pressure-volume loop (PV-loop) changes by cardiac magnetic resonance (CMR) imaging in cardiac amyloidosis (CA) patients with preserved left ventricular ejection fraction (LVEF), and to assess PV-loop parameters' potential as CA subtype differential diagnostic markers. Methods Between May 2017 and September 2023, 100 confirmed CA patients (14 transthyretin [ATTR-CA] and 86 light-chain [AL-CA]) and 40 age- and sex-matched healthy controls (HCs) were prospectively enrolled. PV-loop parameters were derived from CMR cine images and brachial blood pressure. Clinical and CMR parameters were compared between CA patients and HCs, as well as between CA subtypes. The correlations between PV-loop parameters and clinical and imaging parameters were assessed. Furthermore, the differential diagnostic performance of these PV-loop parameters was evaluated using the area under the receiver operating characteristic curve (AUC). Bootstrapping was performed 2000 times for internal validation. Results Compared to HCs, CA patients showed significantly lower stroke work index, potential energy index (PEI), and work efficiency (all P < 0.001). AL-CA patients had higher NT-proBNP levels (2358 [IQR 903.25, 5559] vs. 810 [IQR 269, 1136.01] pg/mL, P = 0.002) and lower PEI (0.13 [IQR 0.07, 0.15] vs. 0.15 [IQR 0.13, 0.19] J/m², P = 0.025) than ATTR-CA patients. NT-proBNP (β = –1.94, OR = 0.14, 95%CI: 0.03-0.64, P = 0.016) and PEI (β = 0.20, OR = 1.23, 95% CI: 1.07-1.44, P = 0.007) were independent predictors for AL-CA vs. ATTR-CA differentiation, and combining these two parameters enhanced the diagnostic performance (bootstrapping AUC 0.847). Conclusion By providing pathophysiological insights into the distinctions of AL-CA and ATTR-CA, PV-loop parameters could serve as a complementary, contrast-free approach for differential diagnosis.graphic abstract
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Liang et al. (2026) conducted an observational in Cardiac amyloidosis (light-chain and transthyretin-related) with preserved left ventricular ejection fraction (n=140). CMR-derived pressure-volume loop parameters (specifically potential energy index [PEI]) and NT-proBNP vs. ATTR-CA vs. AL-CA subtypes and healthy controls was evaluated on Differential diagnosis of AL-CA versus ATTR-CA using potential energy index (PEI) (OR 1.23, 95% CI 1.07-1.44, p=0.007).
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